Southern Grampians Shire Australia Day Awards 2018
Please attach this cover sheet to each nomination.
Please tick the box corresponding to the award category you are nominating.
Australia Day committee(Victoria) / ❏Southern Grampians Shire
Citizen of the Year
If your nominee is unsuccessful in the Citizen of the Year category, would you like this nominee to be considered for the Southern Grampians Shire Council - Community Recognition Award? / ❏ YES
❏ NO
❏Young Citizen of the Year
❏Community Event of the Year
Southern Grampians Shire Council Awards (only) / ❏Community Recognition Award
Please return this completed cover sheet along with the completed
“Southern Grampians Shire Australia Day Awards” nomination forms to:
Chief Executive Officer
Southern Grampians Shire Council
Locked Bag 685, Hamilton, Vic 3300
Ph: 5573 0444 or e-mail
Applications due:5pm Thursday 26 October 2017
Southern Grampians Shire Council
Australia Day Awards 2018
CITIZEN OF THE YEAR AWARD
YOUNG CITIZEN OF THE YEAR AWARD
NOMINATION FORM
NOMINATORS DETAILS (This section is to be completed by the person submitting the nomination form)
Mr/Mrs/Miss......
Address: ...... Postcode:......
Organisation represented (if any)......
Telephone: ......
Signature:......
The Awards are provided by the Australia Day Committee (Victoria) and are administered by Local Government Authorities throughout Australia on behalf of the Council.
Persons who have made a noteworthy contribution during the current year and/or given outstanding service to the local community over a number of years shall be eligible.
AUSTRALIA DAY CITIZEN OF THE YEAR AWARD: / To be eligible, the nominee must be aged 25 years or older on 26 January 2018.AUSTRALIA DAY YOUNG CITIZEN OF THE YEAR AWARD: / To be eligible, the nominee must be under 25 years of age on 26 January 2018.
NOMINATION FOR: / CITIZEN OF THE YEAR
YOUNG CITIZEN OF THE YEAR
NOMINEES DETAILS(This section is to include details about the person being nominated)
Surname: ...... First Name: ......
Occupation......
Private Address:......
Telephone Private: ( )...... Business: ( )......
Date of Birth:...... Age:...... Marital Status:...... Children:......
Please note that all information provided may be used to profile nominees or for publicity. Please provide as much information as you can.
CONTRIBUTION/S TO THE COMMUNITY FOR WHICH THE PERSON IS NOMINATED (please attach examples or evidence. This can be in the form of letters of support from organisations or other members of the community):
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OTHER SIGNIFICANT CONTRIBUTION/S AND ACHIEVEMENT/S(please attach examples or evidence.)
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PAST AND PRESENT MEMBERSHIP OF COMMUNITY/SPORTING/PROFESSIONAL BODIES OR ORGANISATIONS ETC.
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ANY OTHER RELEVANT INFORMATION.
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REFERENCES – PLEASE PROVIDE CONTACT DETAILS FOR OTHER PERSONS WHO CAN BE CONTACTED FOR FURTHER INFORMATION ABOUT THE NOMINEEAND TO SUPPORT THIS NOMINATION
Referee #1
Mr/Mrs/Miss......
Address: ...... Postcode:......
Organisation represented (if any)......
Telephone: ......
Referee #2
Mr/Mrs/Miss......
Address: ...... Postcode:......
Organisation represented (if any)......
Telephone: ......
Completed nomination forms are due by 5pm Thursday 26 October 2017,to: